The Hearing Voices Movement: Beyond Critiquing the Status Quo

Originally posted on:

I am thrilled to have been invited to write about the important and innovative work of the Hearing Voices Movement alongside so many eminent colleagues, critical thinkers and activists working together to bring about an essential revolution in the world of mental health.

We have just celebrated the anniversary of the rapidly expanding, global Hearing Voices Movement which was founded more than twenty-five years ago following the ground-breaking research of Professor Marius Romme and Dr Sandra Escher. Romme and Escher have advocated for a radical shift in the way we understand the phenomenon of Hearing Voices; in contrast to traditional, biomedical psychiatry which views voices as an aberrant by-product of genetic, brain and cognitive faults, their research has firmly established that voices make sense when taking into account the traumatic circumstances that frequently provoke them (Romme and Escher, 1989, 2000, 2009, 2011). While ‘auditory hallucinations’ is the preferred jargon within psychiatric literature, the term ‘hearing voices’, which uses ordinary, non pathologising language framed subjectively, has been reclaimed. This is part of a wider aim within the mental health user movement to decolonise medicalised language of human experience.

Romme and Escher’s research shows that the majority of people who hear voices have had some traumatic experience which they connect with hearing voices.  Subsequent research has confirmed their findings and attests to what many of us with first-hand experience of madness have always known – bad things that happen to you can drive you crazy. However, despite the well-established link between hearing voices and traumatic life experiences, the Hearing Voices Movement explicitly accepts all explanations for hearing voices which may include an array of belief systems, including spiritual, religious, paranormal, technological, cultural, counter cultural, philosophical, medical, and so on. As well as this, we welcome people with a range of experiences, including people who see visions or have other unusual perceptions or sensations.

Within the Hearing Voices Network (HVN) in England which currently has the most well established national network, there are approximately 180 groups currently operating. Groups run mainly in the community but also within statutory and NGO sector services. These include acute psychiatric settings, adolescent services, low, medium and high secure settings. In addition a number of specialist groups for women, people from Black and minority ethnic communities, prisoners, children, young people and parents have also been established. As a respected British consultant psychiatrist recently said, “You clearly represent a movement and constituency that has gone well beyond offering a critique of the status quo and towards representing advocacy and example of alternative approaches which are increasingly being recognised as complimentary or better than traditional approaches”. (Roberts, 2013).

HVN creates sanctuary; safe spaces to share taboo experiences, where there are real possibilities for healing and growth. People are free to share and explore their experiences in detail including the content of what their voices say (Beavan and Read 2010), without the threat of censorship, loss of liberty or forced medication, a common feature of disclosure in traditional psychiatric settings.

As well as our group work, we raise awareness of the benefits of talking about voices, visions and other unusual experiences and the value of peer support. We promote this innovative approach to voice hearers, family members and mental health professionals. We regularly provide training to staff, support on-going research into hearing voices and allied subjects, and liaise with the media which has resulted in a number of positive broadcasts and publications about HVN and voice hearing, both nationally and internationally (Adams 2008; Dillon 2010a; Hilpern 2007; Kirsch 2007; Lakhani 2009: Smith 2007). 

There are now Hearing Voices networks in 26 countries, across 5 continents: Australia, Austria, Belgium, Canada, Denmark, England, Finland, Germany, Greece, Holland, Ireland, Italy, Japan, Kenya, Malaysia, New Zealand, Norway, Palestine, Scotland, South Africa, Spain, Sweden, Switzerland, Uganda, USA and Wales. International developments are co-ordinated via INTERVOICE – the International Network for Training, Education and Research into Hearing Voices – an international organisation dedicated to spreading positive and hopeful messages about the experience of hearing voices across the world.

Representatives and members of the international networks meet annually, at the World Hearing Voices Congresses, to promote new developments, innovative practice, translation of materials, and to support activities in burgeoning countries and share a sense of community, solidarity and camaraderie. One of the fundamental strengths of the Hearing Voices Movement, which has led to its extraordinary success, is that it is based on mutually respectful relationships – authentic partnerships between experts by experience and experts by profession, working together to bring about the emancipation of voice hearers.

HVN’s starting point is that the crises that people experience are real and that they are happening for a reason which is directly connected to the person’s life. We endeavour to support people to make sense of the real events in their lives that may have precipitated their crisis. We show a genuine interest in the range of people’s inner, subjective experiences. When people describe experiences that are deemed ‘psychotic’ we look for the meaning in their madness. Sometimes people use metaphorical or symbolic language to convey their realities and sometimes they are talking literally about things that have happened to them.  However crazy someone appears, we believe that they are making a meaningful attempt to survive maddening experiences.

Contrary to traditional approaches, HVN sees voice-hearing as significant, decipherable and intimately connected to a person’s life story. Consequently, we encourage and support people to listen to their voices and attest to their reality in order to better understand their meaning. We acknowledge that people are having normal reactions to abnormal stress. Instead of asking people – what is wrong with you? We ask them – what has happened to you? On a daily basis we hear stories of physical, sexual and emotional abuse, the impact of neglect, poverty and alienation, as well as of racism, sexism and classism.  Those people, whose experiences do not fit so neatly into a category of trauma as it is currently understood, raise the question of developing our understanding of the huge range of painful and damaging experiences that can be inflicted on and endured by children and adults.

We show respect for the reality of the suffering that people have experienced, and a keen awareness of how this may limit their expression of feelings, ability to think clearly, or capacity to connect. A key part of our role is to magnify the voices of people who are not normally listened to, by promoting the belief that each person has a deep wisdom and expertise about managing and dealing with their own problems. We validate and support people’s resilience, creativity, stamina and emotional strengths, even when they themselves doubt the existence of these qualities.

Acknowledgment enables people to develop true insight into their own distress and suffering which leads to an increasing sense of meaning and purpose in their lives. We are interested in people’s subjective experiences – including their altered states of consciousness, unusual perceptions, ideas and ways of seeing and experiencing the world. When your own feelings, thoughts, experiences and bodily sensations, begin to make sense to you, insight is a natural consequence. When you understand your own ‘symptoms’ as meaningful and essential survival strategies, a more respectful and loving acceptance of yourself begins to emerge (Bullimore 2009; Dillon 2010b; Lampshire 2009; Longden 2010; McNamara 2011).

We recognise that recovery is an on-going process with no fixed end point and that each person’s recovery is unique. HVN recognises that crises may occur again because recovery is an evolving process, an expansive process not a reductive one which seeks to control and maintain people. We have faith in people’s inherent right and capacity to heal, to make mistakes, to learn and to grow. We know that there is much about human experience that we do not understand and we remain humble and curious and open to new ways of seeing the world. We are not interested in complying with social control or in servicing normality. ‘Instead of being a list of symptoms, with side effects on top, we are people who hear voices and see visions, have unusual thoughts, passionate feelings, intense experiences’(Dillon and May 2002). We celebrate our differences.

For many voice hearers and psychiatric survivors, active participation and social action supports and enhances the recovery process; having a shared survivor mission ( Herman, 1992), and becoming part of a collective voice creating change in the world, both inside and out,  is healing, empowering and liberating. This is also true for many mental health workers, who have become increasingly disillusioned with an inadequate biomedical model, disturbed by the collusion demanded of staff in a mental health system driven by fear, control and bureaucracy. For them, becoming part of the Hearing Voices Movement also enables a recovery of meaning, purpose and optimism, a renewal of important values, a rediscovering of a sense of self. For all of us, the possibility of reconnecting to ourselves and each other as unique and equal human beings, is life affirming.

Questions, comments and/or reflections are welcome on this website or via Twitter @JacquiDillon


Intervoice –

Hearing Voices Network, USA:

Hearing Voices Network, England:


Adams, W. (2008). The Listening Cure. Time, 21 February.

Beavan, V. and Read, J. (2010). Hearing voices and listening to what they say. Journal of Nervous and Mental Disease 198: 201-5.

Bullimore, P. (2009). My personal experience of paranoia. Psychosis 2: 173-7.

Dillon, J. and May, R. (2002). Reclaiming experience. Clinical Psychology 17: 25-77.Dillon,

J. (2010a).

Dillon, J. (2010b). The tale of an ordinary little girl. Psychosis 1: 79-83.

Herman, J. (1992). Trauma and recovery. New York: Basic Books.

Hilpern, K. (2007). How I beat the voices in my head. The Independent,  Mar. 6.

Kirsch, M. (2007). Voices in your head? You may not be crazy. The Times, 23 January.

Roberts, G. (2013). Personal communication.

Lakhani, N. (2009). A first-class recovery. Independent on Sunday, 25 October.

Lampshire, D. (2009). Lies and lessons: ramblings of an alleged mad woman. Psychosis 1: 178-84.Romme, M. and Escher, S. (1989). Hearing voices. Schizophrenia Bulletin 15: 209-16.

Longden, E. (2010). Making sense of voices: a personal story of recovery. Psychosis 2: 255-9.

McNamara, J. (2011). Can we sit and talk? Poems stories and some words of advice. Psychosis 3: 167-71.

Romme, M. and Escher, S. (1989). Hearing voices. Schizophrenia Bulletin 15: 209-16.

Romme, M. and Escher, S. (2000). Making Sense of Voices. London: Mind.

Romme, M. Escher, S. Dillon, J. Corstens, D. Morris, M. (eds.). (2009). Living with Voices: 50 Stories of Recovery. PCCS Books.

Romme, M. and Escher, S. (eds) (2011). Psychosis as a Personal Crisis. London: Routledge.

Smith, D. (2007). Can you live with the voices in your head? New York Times, 25 March.

Trauma, Dissociation, Attachment & Neuroscience: A new paradigm for understanding severe mental distress

Special Edition: Complex reactions to severe trauma

The paper by Dillon, Johnstone & Longden in this volume (Trauma, Dissociation, Attachment and Neuroscience) brings together evidence from the neuroscience and mental health literature with the hope that this might lead to a paradigm shift in the way that people are seen and helped. Hopefully they are right, and biopsychosocial models worthy of the name may come to dominate practice, rather than models that sometimes masquerade as biopsychosocial but which are basically ‘bio-bio-bio models’, with social and psychological factors reduced to mere events that trigger an underlying genetic illness (Read, Bentall & Fosse, 2009).

JCPCP is a peer-reviewed journal which values personal experience above professional boundaries and doctrinal jargon. It provides a forum for ideas, experience and views of people working in the psychological world and those who use psychotherapy or receive psychiatric services. The journal encourages a critical, reflexive view of psychology and counselling and is a constant challenge to orthodoxy. Our contributors reflect on their work and experiences in therapy, in relationships and in institutions. The journal embraces philosophical, radical and scientific perspectives in its analysis of psychological, psychiatric and psychotherapeutic systems. With a following wind, it will sometimes make you laugh out loud.


Watch Keynote Presentation The Personal is Political Online


Here is a link to my recent presentation ‘The Personal is the Political’ which was filmed at the Critical Perspectives and Creative Responses to Experiences of Trauma and Distress Conference at University College Cork, Ireland:

This was a fantastic free event, attended by over 450 people over two days was organised by the School of Nursing & Midwifery & School of Applied Social Studies: 

and Critical Voices Network Ireland. See: 



New Foreign Correspondent for Mad in America

I am thrilled to have been invited to become a foreign correspondent for the Mad in America web site – see:

I will be writing about the important and innovative work of the Hearing Voices Movement alongside many eminent colleagues, critical thinkers and activists working together to bring about an essential revolution in the world of mental health.

You can read my first post here:

About Mad in America:

The site is designed to serve as a resource and a community for those interested in rethinking psychiatric care in the United States and abroad. We want to provide readers with news, stories of recovery, access to source documents, and the informed writings of bloggers that will further this enterprise.

The bloggers on this site include people with lived experience, peer specialists, psychiatrists, psychologists, social workers, program managers, social activists, attorneys, and journalists. While their opinions naturally vary, they share a belief that our current system of psychiatric care needs to be vastly improved, and, many would argue, transformed.

We also want to provide readers with the opportunity to add their voices to this discussion. We encourage readers to leave comments (see comment policy below), and to submit recovery stories and op-ed submissions. We encourage our readers to visit our forums to further this communal discussion.

Finally, we are commissioning original journalism, both in video and print, that explore on-going efforts to remake care in the U.S. and abroad, and also investigate the problems and deficiencies with the current drug-based paradigm of care.

We welcome feedback and comments on how we can improve this website, and continue to build an online community that can be a societal force for change.

Our Legal Organization

When we started this initiative, we investigated whether it would be better to operate as a non-profit organization, or as a C corporation. We chose the latter, as it provided us with a quicker and easier way to obtain initial funding from “investors” for creating the website and supporting its development. The president of the C Corp is Robert Whitaker. The other board members are Louisa Putnam, Kermit Cole, Laura Delano, and Matthew Cohen.

For on-going revenue to sustain this initiative, we are entirely dependent on support from our readers. We do not host advertisements and do not sell data about our readers to anyone.

Policy for Posting Comments

Please see our guidelines for posting comments on this site.


Mad In America is supported entirely by user donations. Please click here to join in support of our mission.

Exciting new Hearing Voices Research & Development Fund in USA

Hearing Voices Research & Development Fund

The Hearing Voices Research and Development Fund has been established to advance the development of the Hearing Voices Approach in the U.S. The Project was created by Gail A. Hornstein, Professor of Psychology at Mount Holyoke College, and Jacqui Dillon, National Chair of the Hearing Voices Network in England, who have been working together for 10 years to bring new approaches to understanding and coping with voice hearing.

People who hear voices, see visions, or experience other extreme states often end up being diagnosed as psychotic (usually with schizophrenia) and a poor prognosis. The medications which have routinely been prescribed for such patients since the 1950s are effective for some but not for others, and even when they do work, their benefits typically diminish over time, while destructive physical and psychological side effects become increasingly problematic. Hearing voices in particular remains a challenge for many, many patients even after they have been tried on every possible medication over many years, and continues to be seen by many psychiatrists as a “treatment-resistant” symptom.

Hearing Voices Approach
For the past 25 years, the Hearing Voices Network – an international collaboration of professionals, people with lived experience, and their families and friends – has been working to develop an alternative approach to coping with voices, visions, and other extreme states that is empowering and useful and does not start from the assumption that people who have these experiences suffer from a chronic illness. A large body of research data, published in major professional journals, now provides support for key aspects of this approach (see references below), and the hundreds of peer-support groups that have developed in 20 countries around the world are enabling voice hearers – even those who have been chronically disabled – to learn to cope more effectively or rid themselves of the negative effects of their voices. These groups are now starting to spread across the US, but the lack of a systematic program for training potential facilitators and others interested in incorporating HVN’s work into their research or teaching is holding the United States back from being able to offer this effective, community-based psychosocial alternative to the current risky practice of large-dose, long-term treatment with (usually multiple) medications.

Hearing voices peer-support groups offer a safe place for people to share their experiences of voices, visions, tactile sensations and other unusual experiences and perceptions. People meet together to help and support each other, to exchange information, and to learn from one another’s coping strategies. Groups also offer an opportunity for people to accept and “live with voices” in a way that enables them to regain some control over their lives.

The situation in the US stands in striking contrast to that of other countries. For example, England (a country with a population of 60 million) has 180 hearing voices groups, and Denmark (a country of 5 million) has several dozen, whereas the US, with its population of over 300 million, currently has only about 15. The fund will support the development of HVN groups across the US by providing a systematic program of training that will create a network of hearing voices peer-support groups in key centers in each region of the country. Participants will be selected using a rigorous model in which mental health professionals and voice hearers collaborate in an intensive shared learning experience that equips them to apply HVN’s concepts and methods to the creation of positive alternatives for people diagnosed with psychosis.

Hearing Voices Research
The fund will also support a research study to provide the kinds of basic phenomenological descriptions of the voice hearing experience that have become increasingly essential to other research in this area.

Even though more and more researchers have become interested in investigating the complexities of voice hearing in and of itself (as opposed to treating it simply as one of a number of so-called “positive symptoms” of schizophrenia), the lack of a clear identification of the defining characteristics and significance of the experience for voice hearers makes it difficult to compare results across different studies. In addition, as colleagues from HVN have highlighted in their work (see references below), there is no evidence for the standard assumption that patients who hallucinate cannot articulate the triggers, contextual variability, or meaning of their experiences. The few phenomenological studies that have been conducted thus far demonstrate clearly that understanding the subjective experience of voice hearers themselves is essential to the ultimate effectiveness of any intervention designed to help them.

The Foundation for Excellence in Mental Health Care

We are a group of scientists, psychiatrists, researchers, public policy analysts, users and providers of mental health services, philanthropists, and community members that formed The Foundation for Excellence in Mental Health Care to find and promote the best ways to achieve long-term recovery and help people with mental health challenges to thrive.

The Foundation was established in response to nationwide interest in Robert Whitaker’s book, Anatomy of an Epidemic, and the desire to examine existing research, create support for new innovative research and programs, and sponsor symposia to build a new paradigm of care that focuses on long-term recovery and wellness. 

Strong evidence demonstrates that our 25-year long over-reliance on a purely medical model has not advanced mental health recovery. The number of individuals diagnosed with “chronic mental illness”, disabling enough to place them on the Social Security roles has tripled since 1987.

The Foundation has established a Scientific Advisory Committee and Community Advisory Committee to guide our activities of mental health reform.

For More Information:

Selected References
Beavan, V. (2011). Towards a definition of “hearing voices”: A phenomenological approach. Psychosis: Psychological, Social and Integrative Approaches, 3, 63-73.

Dillon, J. (2006, November). Collective voices. Open Mind.

Dillon, J. and E. Longden (2012) Hearing voices groups: Creating safe spaces to share taboo experiences. In M. Romme and S. Escher (eds.), Psychosis as a personal crisis: An experience-based approach. London: Routledge.

Honig, A., M. Romme, B. Ensink, S. Escher, M. Pennings and M. Devries (1998). Auditory hallucinations: A comparison between patients and non-patients. Journal of Nervous and Mental Disease, 186, 646-651.

Hornstein, G.A. (2009). Agnes’s Jacket: A Psychologist’s Search for the Meanings of Madness. New York: Rodale Books. (UK edition, with a new introduction, PCCS Books, 2012)

Johns, L.C., J. Y. Nazroo, P. Bebbington and E. Kuipers (2002). Occurrence of hallucinatory experiences in a community sample and ethnic variations. British Journal of Psychiatry, 180, 174-78.

Lakeman, R. (2002). Making sense of the voices. International Journal of Nursing Studies, 38, 523-531.

Martin, P.J. (2000). Hearing voices and listening to those that hear them. Journal of Psychiatric and Mental Health Nursing, 7, 135-141.

Romme, M. and S. Escher (1989). Hearing voices. Schizophrenia Bulletin, 15, no. 2, 209-216.

Romme, M. and S. Escher (eds.). (1993; 2nd ed. 1998). Accepting Voices. London: MIND Publications.

Romme, M. and S. Escher (1996). Empowering people who hear voices. In G. Haddock and P. Slade (eds.), Cognitive Behavioral Interventions with Psychotic Disorders. London: Routledge, pp.137-150.

Romme, M. and S. Escher (2000). Making Sense of Voices: A Guide for Mental Health Professionals Working with Voice-Hearers. London: MIND Publications.

Romme, M. and S. Escher (2005). Trauma and hearing voices. In W. Larkin and A. Morrison (eds.) Trauma and Psychosis: New Directions for Theory and Therapy. London: Routledge.

Romme, M., S. Escher, J. Dillon, D. Corstens and M. Morris (eds.). (2009). Living with Voices: 50 Stories of Recovery. Ross-on-Wye, UK: PCCS Books.

Romme, M., A. Honig, E.O. Noorthoorn and S. Escher (1992). Coping with voices: An emancipatory approach. British Journal of Psychiatry, 161, 99-103.

Sayer, J., S. Ritter and K. Gournay (2000). Beliefs about voices and their effects on coping strategies. Journal of Advanced Nursing, 31, 1199-1205.

Royal College of Psychiatrists: Abolish use of formal psychiatric diagnostic systems like ICD & DSM

Abolish use of formal psychiatric diagnostic systems like ICD & DSM

Psychiatric diagnoses are not valid.
Use of psychiatric diagnosis increases stigma.
Using psychiatric diagnosis does not aid treatment decisions.
Long term prognosis for mental health problems has got worse.
Psychiatric diagnosis imposes Western beliefs about mental distress on other cultures.
Alternative evidence based models for organizing effective mental health care are available.

To sign the petition please go to this link:

To read the full evidence based arguments view the ‘No More Psychiatric Labels’ paper at which is reproduced below:

Modern Western psychiatry has secured many important advances in the care of people with mental distress. We have a variety of pharmacotherapies that can help manage distressing symptoms alongside an even greater variety of psychotherapeutic approaches that help people in distress make sense of their experiences and find new ways to deal with them. The old asylums have been emptied and community care has developed a rich variety of services from early intervention to crisis management. Researchers have identified many biological and environmental factors associated with greater likelihood of having or developing mental health problems and so our understanding of mental distress has improved. Reflecting this, the academic community, studying mental distress from a variety of angles has grown in numbers and sophistication with many journals and thousands of articles being published each year. These are worthy achievements and this progress has no doubt helped thousands of people across the world.

However, despite all these achievements, psychiatric theory and practice has reached an impasse. Prevention has proved elusive with mental health diagnoses becoming more not less common despite a large increase in services in most developed countries. There still isn’t a diagnosis listed in the major psychiatric diagnostic manuals (such as ICD and DSM) that is associated with any sort of physical test and so, unlike the rest of medicine, aetiology has an insignificant part to play in organising diagnostic practice. Whilst reliability in making diagnoses has improved for some research purposes, this does not necessarily translate to clinical practice and the more important issue of validity remains poorly addressed. Most importantly there is no evidence to show that using psychiatric diagnostic categories as a guide for treatment leads, through evidence based choices, to improved outcomes. There is some evidence to suggest that applying a psychiatric diagnosis and theoretical models associated with them instead leads to a worse outcome for some.

This campaign therefore proposes that the time has come to help theory and practice in mental health move beyond this impasse by abolishing formal psychiatric diagnostic systems like ICD and DSM. By incorporating the latest evidence from epidemiology, cross-cultural studies and treatment outcome studies, the campaign highlights the extent to which the data is inconsistent with the dominant, diagnostic based, medical model remaining as the organising paradigm for practice. Continuing to use formal diagnostic systems to organise research, training, assessment, and treatment for those in mental distress is inconsistent with an evidence based approach capable of improving outcomes. Whilst the important task of sketching out what services may look like once we discard ICD and DSM from routine clinical practice is not the primary purpose of this campaign, a few pointers are also mentioned to highlight that alternative paradigms are already available and easy to incorporate into practice and in a way that can improve outcomes.


The failure of basic science research to reveal any specific biological abnormality or for that matter any physiological or psychological marker that identifies a psychiatric diagnosis is well recognised. Unlike the rest of medicine, which has developed diagnostic systems that build on an aetiological framework, psychiatric diagnostic manuals such as DSM-IV and ICD-10 have failed to connect diagnostic categories with any aetiological processes. Thus there are no physical tests referred to in either manual that can be used to help establish a diagnosis. The critique that highlights the lack of progress on aetiology is not limited to those less biologically minded psychiatrists as researchers in genetics are also arguing that the use of categorical diagnoses (such as schizophrenia) is handicapping their studies too, where, they argue, a dimensional approach seems more appropriate;3,4 although it should be noted that dimensional approaches in the rest of medicine often focuses on a very small percentage of ‘outliers’ (e.g. growth hormone treatment for short stature) rather than the large numbers currently attracting the gaze of psychiatry.

The one notable exception to the lack of aetiological organisation is the diagnosis ‘Post Traumatic Stress Disorder’ (PTSD) which attributes symptoms to being the direct result of trauma. This diagnosis did not develop out of new scientific discoveries but as a result of legal procedures (the construction of ‘PTSD’ came largely as a result of legal battles involving US military veterans of the Vietnam War) and its use implies that other diagnoses are not related to trauma. However, there is a substantial body of evidence linking states regarded as the most serious in psychiatry, such as the experience of hearing voices and psychosis, to trauma and abuse including sexual, physical and racial abuse, poverty, neglect, and stigma. 5, 6,7,8,9,10,11,12,13,14 This is why it is important to attempt to understand psychotic experiences in the context of the person’s life story. Not to do so can be harmful because it obscures and mystifies the origins of problematic experiences and behaviour that has the potential to be understood.14


If we were to apply the standards found in the rest of medicine then the validity of a diagnostic construct depends on the extent to which it represents a naturally occurring category. If it does, then there should be some identifiable biological property in those who have the diagnosis that can distinguish them from those who don’t. Despite years of searching for biological correlates, the failure of basic science research to reveal any specific biological marker for any psychiatric diagnostic category reveals that current psychiatric diagnostic systems do not share the same scientific security of belonging to the biological sciences as the rest of medicine. Mainstream practice understandably views this as a problem. However, the attempted solution of continuing to spend the bulk of mental health research time and effort trying to correct this deficit by relentlessly searching for evidence of biological correlates continues to deliver nothing clinically useful. Our failure to find biological correlates should not necessarily be seen as weakness. Instead of continuing with scientifically and clinically fruitless research we should view this failure as an opportunity to review the dominant paradigm in order to develop one that better fits the evidence.

Invalid anomalies are prevalent in DSM/ICD. For example, in DSM defined ‘depression’ there is one exception to the diagnosis (even if the patient has the required number of symptoms for the required number of weeks) – bereavement. This is anomalous in at least two ways. Firstly it breaks the ‘rule’ that diagnostic categories in DSM are descriptors that do not imply aetiology. Secondly, because bereavement is considered a ‘normal’ reaction, even if the full complement of DSM defined symptoms of depression are present, then one must ask: why is ‘bereavement’ specifically singled out? Why are many other life problems for which intense sadness is a common response – such as losing a job, break up of a marriage, bullying and so on – not also counted as legitimate exceptions?16

The frequency with which patients are given more than one diagnosis also raises a concern about the specificity of diagnostic categories. Widespread co-morbidity (making more than one diagnosis in order to encompass patients’ problems) indicates basic deficiencies in our understanding of the natural boundaries of even the most severe conditions we are diagnosing in psychiatry.17,18,19 It is also common to find the ‘dominant’ diagnosis changing in any individual, almost exclusively on a subjective rather than empirical (such as physical test results) basis. Unlike in the rest of medicine where the reason for the patient’s symptoms is clarified by a diagnosis, psychiatric diagnoses serve empirically as nothing much more than descriptors. Thus, when a clinician claims that a patient is ‘really’ depressed, or has ADHD, or has bipolar disorder, or whatever, not only are they trying to turn something based on subjective opinion into something that appears empirical, but they are engaging with the process of reification (turning something subjective into something ‘concrete’). The problem with turning concepts into something that appears as if it exists as a fact in the natural world is that it can cause ‘tunnel vision’ for all concerned; a dominant story that limits alternative more functional possibilities for any individual.20 Thus if someone believes ADHD is a ‘real’ disorder that exists in their brains and is potentially lifelong, that person and those who know them may come to act according to this belief, thus helping to fulfil its prophecy.

There is also a poor correspondence between levels of impairment and having the required number of symptoms for many psychiatric diagnoses (even though ‘impairment’ is often included in the diagnostic criteria). Literature reviews and field trials to examine clinical significance criteria were not included in the preparation of DSM-IV. Thus many below the threshold for a diagnosis have higher levels of impairment than those above, with many who reach the cut off for a diagnosis having relatively low levels of impairment. 21,22,23


Reliability is the extent to which clinicians can agree on the same diagnoses when independently assessing a series of patients. Over the last thirty years or so, academic psychiatrists have worked hard to improve the reliability of psychiatric diagnoses. This is partly in response to critics of psychiatry who pointed out that many of the common diagnoses in use at the time were meaningless because of poor levels of agreement between psychiatrists about key symptoms. Rosenhan’s 1973 study spurred on new attempts to ‘standardise’ diagnostic practice after he demonstrated that psychiatrists were often unable to discriminate between sane and psychotic people.24 Formal diagnostic systems like DSM and ICD attempted to address these problems by imposing diagnostic agreement on the profession through the use of standardised check-lists of symptoms for diagnostic criteria. Because of the repeated claim that this approach has improved reliability significantly, the diagnostic systems now in use give the impression of being reliable in an empirically verifiable way.

However, analysis of the studies involved in developing the first diagnostic manual that took this approach of ‘operationalising’ diagnosis through the check list of symptoms approach (DSM-III), found no diagnostic categories for which reliability in these studies was uniformly high. The ranges of reliability for major diagnostic categories were found to be very broad and in some cases ranged the entire spectrum from chance to perfect agreement, with the case summary studies (in which clinicians are given detailed written case histories and asked to make diagnoses – an approach that most closely approximates what happens in clinical practice) producing the lowest reliability levels.25 No studies of the reliability of DSM as a whole when used in natural clinical settings have shown uniformly high reliability, with many finding reliability ratings that are not that different than those in the pre-DSM-III studies. 25,26,27 To overcome this, developers of subsequent DSMs have simply de-emphasised the reliability problem, claiming this to have already been solved by the approach developed in preparing DSM-III.

Treatment and outcome

The technological paradigm is the dominant one that organises the way psychiatric services and treatments are delivered in most industrialised countries. This paradigm is predicated on the assumption that the technical aspects of medical and psychological care are of primary importance, and that these can be applied through making diagnoses and then applying corresponding treatment protocols.

However, there is a large literature on psychotherapy confirming that it is generally speaking a safe and effective intervention for common mental health problems as studied in Western populations, but there is little to suggest that a positive outcome is strongly related to selecting the ‘correct’ psychotherapeutic technique and much to suggest that the ‘common factors’ such as developing a strong therapeutic alliance, are more important.28,29,30 For example, several studies have shown that most of the specific features of Cognitive Behaviour Therapy (CBT) can be dispensed with, without adversely affecting outcomes. 31,32 The same holds for other forms of psychotherapy for depression. For example, The National Institute of Mental Health’s Treatment of Depression Collaborative Research Project (TDCRP), the largest trial to date comparing different treatments for depression (CBT, Inter-Personal Therapy [IPT], anti-depressants, and placebo) found that patients in each group had significant improvements, with no overall difference in outcome between each treatment group. However, the best predictor of outcome across all four groups was the quality of the relationship between patient and therapist (as perceived by the patient) early in treatment. 33,34, 35, 36

Recent meta-analyses have drawn similar conclusions. The quality of the therapeutic alliance accounts for most of the within-therapy variance in treatment outcome, and is up to seven times more influential in promoting change than treatment model. 28,37 Such data, when combined with the observed superior value, across numerous studies, of clients’ assessment of the relationship in predicting the outcome, makes a strong empirical case that the non-specific aspects of psychotherapy, or ‘know-how’ in building a strong therapeutic alliance, are more important than specific techniques being used. This is also evident in ‘real life’ clinical encounters not just research projects. For example, in a review of over 5000 cases treated in a variety of National Health Service settings in the UK, only a very small proportion of the variance in outcome could be attributed to psychotherapeutic technique, as opposed to non-specific effects such as the therapeutic relationship.38

The same principles can be found operating when using psychoactive drug treatments (that non-specific factors are more important than matching a drug to a diagnosis). Thus a number of psychiatrists have argued that instead of correcting imbalances, the evidence supports the view that pharmacological agents may be conceptualised as inducing particular psychological states which, though not specifically related to diagnosis, is nonetheless the basis for their usefulness.39 This reflects clinical practice where the few categories of psychoactive medications used in psychiatry (the SSRIs, major tranquilisers, benzodiazepines, Lithium, and anti-epileptics) are often used in a non-diagnosis specific way. For example, SSRIs are claimed to be efficacious in conditions as disparate as borderline personality disorder, depression, obsessive compulsive disorder, anorexia nervosa, bulimia, panic disorder, social phobias, and so forth. As a psychoactive substance SSRIs would appear to do ‘something’ to the mental state, but that something is not diagnosis specific. Like alcohol, which will produce inebriation in a person with schizophrenia, obsessive compulsive disorder, depression, or someone with no psychiatric diagnosis, SSRIs will also impact individuals in ways that are not specific to diagnosis. Similarly, major tranquilisers (misnamed anti-psychotics) have also been advocated for the treatment of depression, anxiety disorders, bipolar affective disorder, personality disorders, ADHD, as well as schizophrenia, a list that contains considerable overlap with that found for SSRIs.

Many psychiatric drug treatments, like psychological treatments, rely more on non-specific factors than disease-specific therapeutic effects. For example, it is generally assumed that drugs marketed as ‘antidepressants’ work through their pharmacological effects on specific neurotransmitters in the CNS, reversing particular states of ‘chemical imbalance’. However, the evidence points to placebo effects being more important than any neuro-pharmacological ones. Thus several meta-analyses have concluded that most of the benefits from ‘antidepressants’ can be explained by the placebo effect, with only a small amount of the variance (about 20%) attributable to the drug, a small amount moreover that is unlikely to be clinically significant for the vast majority of patients.40,41 Studies investigating the degree to which non-technical factors such as therapeutic relationship affect outcome, have found that even with psychoactive drug treatments these factors are far more influential than the drug alone. Thus having a good relationship with the prescribing doctor is a stronger predictor of a positive response to an ‘anti-depressant’ than just taking the drug regardless of who prescribes it. 28,42

The lack of treatment specificity is not limited to the more common and less severe presentations. Thus, although drugs marketed as ‘antipsychotic’ are often claimed to reverse a biochemical imbalance in psychotic patients, no such imbalance has been demonstrated. Furthermore, researchers have long been aware of a perplexing finding in cross-cultural studies. Research, including that carried out by the World Health Organisation, over the course of 30 years and starting in the early 1970s, shows that patients outside the United States and Europe have significantly lower relapse rates and are significantly more likely to have made a ‘full’ recovery and show lower degrees of impairment when followed up over several years despite most having limited or no access to ‘anti-psychotic’ medication. It seems that the regions of the world with the most resources to devote to mental illness – the best technology, medicines, and the best-financed academic and private-research institutions – had the most troubled and socially marginalised patients.43 Once again the impact of our psychiatric technologies seem to be minimal compared to common factors, in this case most likely to be the effects of ‘extra-therapeutic’ factors such as family support, community cohesion and tolerance for behaviours and experiences considered a sign of ‘illness’ and ‘dangerousness’ in the West.


Unlike the rest of medicine, no overall improvement in prognosis has been demonstrated in Europe and North America over the past century for those diagnosed with a mental disorder. Some studies indicate the opposite, that compared to the pre-psychopharmacology period there are more patients who have developed chronic conditions such as chronic schizophrenia than in the past. For example, in 1955, there were around 350 thousand adults in the US state and county mental hospitals with a psychiatric diagnosis. During the next three decades (the era of the first generation psychiatric drugs), the number categorised as disabled from mental illness rose to 1.25 million. By 2007 the number of people categorised as disabled mentally ill grew to more than 4 million adults. Similarly, the numbers of youth in America categorised as having a disability because of a mental condition leapt from around 16 thousand in 1987 to 560 thousand in 2007.44

Studies that have compared outcomes for psychotic disorders such as schizophrenia have repeatedly found that outcomes are better in poorer, non-developed countries when compared to richer, more industrialised ones.41 For example, the World Health Organisation’s international outcome in schizophrenia studies found that after 2 years about two thirds of the patients in the poor countries were doing well compared to only a third of the patients in the developed countries. The researchers concluded that “being in a developed country was a strong predictor of not attaining a complete remission.”45 Thus the progress attributable to modern mainstream psychiatric diagnostic based practice does not extend to improved prognosis.

One problem with medical model diagnostic approaches is that many of the diagnoses (such as schizophrenia, bi-polar disorder, dysthymia, ADHD, autism, OCD etc.) are conceived as conditions that are genetic and lifelong in nature (i.e. conceived as chronic conditions that are ‘hard-wired’ with little chance of making a complete recovery), where the best one can hope for is gaining some control over symptoms (through, for example, life-long use of medications). This constructs and often imposes a narrative of despair on those diagnosed with these ‘chronic’ conditions. As such psychiatric diagnoses can foreclose meaning by transforming a range of experiences and possible meanings that can be applied to these experiences into a narrow disease framework, limiting the cultural imagination to expecting largely negative outcomes.

Prognosis for those with mental disorders is also further hampered by the stigma associated with the medical model.46 Nearly all studies that have looked at the question of public attitudes toward mental illness have found an increase in biological causal beliefs across Western countries in recent years.47 However, biological attributions for mental illness are overwhelmingly associated with negative public attitudes such as a belief that patients are unpredictable and dangerous with associated fear of them and greater likelihood of wanting to avoid interacting with them. 48 Conversely, in studies where members of the public are given a psychosocial explanation for the sufferer’s symptoms (such as serious life events, loss, trauma etc.) they are much less likely to give negative attributions.48 Yet again, the ‘medical model’ diagnostic approach has a significantly negative impact causing an increase in stigma rather than a reduction.

Similar findings emerge in personal stories of those diagnosed with a ‘mental illness’. Through social action, the survivor movement has created safe spaces in which individuals can start the process of telling their own stories. Many of these stories show that users of mental health services felt stigmatised and marginalised by a psychiatric diagnosis, experiencing this as something that leads to the loss of ‘citizenship’.46,49 Being labelled with a chronic ‘genetic’ condition such as ‘schizophrenia’ interferes with a person’s identity and biography. Indeed, the presence of ‘insight’ (as defined by doctors) in schizophrenia has been found to lower self-esteem and can lead to despair and hopelessness.50 Paradoxically, it has been found that the presence of this type of ‘insight’ (meaning accepting you are mentally ill and need medical treatment) is negatively correlated with emotional well-being, economic satisfaction and vocational status. 51,52, 53 Thus accepting the medical model attitude to diagnosis brings expectations of a gloomy outlook with lifelong dependency on psychiatric treatment and little chance of a good recovery. For some therefore, rejecting the diagnosis (or ‘lack of insight’) may be understood as a positive way of coping with the implications of the diagnosis for personal identity.52,53

In summary it seems we now have good evidence that the diagnostic ‘illness like any other illness’ approach is likely to be contributing to a worse prognosis for those diagnosed, not better.


For the last few decades Western mental-health institutions have been pushing the idea of ‘mental-health literacy’ on the rest of the world. Cultures are viewed as becoming more ‘literate’ about mental illness the more they adopted Western biomedical conceptions of diagnoses like depression and schizophrenia. This is because of a belief that ‘modern’, ‘scientific’ approaches reveal the biological and psychological basis of psychic suffering and so provide a rational pathway to dispelling pre-scientific approaches that are often viewed as harmful superstitions. In the process of doing this we not only imply that those cultures that are slow to take up these ideas are therefore in some way ‘backward’, but we also export disease categories and ways of thinking about mental distress that were previously uncommon in many parts of the world. Thus conditions like depression, post-traumatic stress disorder, and anorexia appear to be spreading across cultures, replacing indigenous ways of viewing and experiencing mental distress.54,55 In addition to exporting these beliefs and values, Western drug companies see in such practice the potential to open up new and lucrative markets.54,56

Despite copious evidence from research in the non industrialised world, that shows the outcomes for major ‘mental illnesses’, is consistently better than in the industrialised world and particularly amongst populations who have not had access to drug based treatments,43,44,45 the World Health Organisation, together with the pharmaceutical industry, has been campaigning for greater ‘recognition’ of mental illnesses in the non-industrialised world, basing their assumptions on the idea that ICD/DSM descriptions are universally applicable categories.57 Like other marketing campaigns, this strategy has the potential to open up huge new markets for psychiatric drugs that maybe ineffective and can have serious side effects, at the same time as painting indigenous concepts of, and strategies to deal with, mental health problems, as being based on ignorance, despite their obvious success for these populations.

The idea of the individual as the locus of the self is a relatively recent Western invention and such a framework creates the psychological pre-conditions necessary for accepting the ‘atomised’ social worlds that have been created. Yet, mental well-being seems closely connected to social and economic factors. Several international studies have concluded that more important than poverty per se is the degree of inequality. Thus the greater the inequality (in economic and social resources) in any society, the poorer is the mental health of that society.58,59,60,61,62

A more subtle source of impact on cultural beliefs is due to psychiatric diagnoses inadvertently setting standards for ‘normality’, by categorising what emotional and behavioural traits and experiences should be considered ‘disordered’. As the criteria for diagnoses are arrived at by subjective judgments rather than objective evidence (being literally voted in or out of existence by committees), they will have an automatic bias toward the cultural standards found in economically dominant societies (who also tend to control what counts as ‘knowledge’ globally). This sets in motion a diagnostic system vulnerable to institutional racism in the dominant societies and colonialism in others, as other standards of normality will, at least to some extent, come to be viewed as ‘primitive’, ‘superstitious’ etc. and their populations will be viewed as needing to be (psycho)educated. As a result then, for the majority of the world, all manner of complex somatic/emotional complaints have to be re-categorised, spiritual explanations have to be denounced, parenting practices viewed as oppressive and so on.

Thus imposing Western medical model DSM/ICD style psychiatry on non-Western populations risks a number of things including: adoption of Western psychiatric notions of ‘psychopathology’ to express mental distress, undermining of existing cultural strategies for dealing with distress, more not less stigma for those with mental health problems, and the imposition of an individualistic approach that may marginalise family and community resources and divert attention from social injustice.

Cultural and Public policy impact

Despite adopting a DSM/ICD approach causing many problems for translating the subjective process of attaining a psychiatric diagnosis into a reliable and objective one in clinical practice; it has nonetheless had a significant impact on service provision and public and professional beliefs about mental distress. As a result of popularising the diagnostic systems created by DSM/ICD, it is widely argued that a significant proportion of the population suffers from mental illness, that this amounts to a significant economic burden, and that there is a strong case for investing in improved mechanisms of detection and treatment for these disorders. Across several surveys in the industrialised nations only about a third of those identified as suffering a mental health problem (according to DSM/ICD criteria) sought or were interested in seeking professional help.63,64,65,66 This has been interpreted as unsatisfactory case detection, provision and treatment, due to public and professional ignorance. However, there is little evidence to support the idea that popularising mental health diagnoses, convincing professionals and the public about the high prevalence of mental disorders, and convincing policy makers of the need to diagnose and treat more people, benefits the mental health of the society.

In order to increase rates of diagnosis and treatment, a variety of campaigns have been undertaken. For example, in the UK the Royal College of Psychiatrists and Royal College of General Practitioners launched their ‘Defeat Depression’ campaign in the early nineties. 67 It was intended to raise public awareness of depression, reduce stigma, train general practitioners in recognition and treatment, and make specialist advice and support more readily available. Unfortunately, evaluations of treatment and education guidelines in the UK following the ‘Defeat Depression’ campaign failed to detect significant improvements in clinical outcome.68,69,70 However, other effects of the campaign included a rapid increase in antidepressant prescribing and increased medicalisation of unhappiness and distress. As has been noted above, medicalisation of mental distress through promotion of the idea that mental health problems are best understood as ‘illness like any other illness’, increases rather than decreases stigma.

Unlike other areas of public health, mental health in those societies with the most developed services appears to be the poorest. In such societies ‘epidemics’ of psychiatric diagnoses (e.g. ADHD, autism, depression, bipolar disorder) have only emerged and become popularised in recent years. Whilst there are complex political, social and cultural reasons for this, they are in part based on new categories and ideas about personhood, the nature of distress etc. and so are at least in part the result of creating, broadening and popularising psychiatric diagnoses.


For any diagnostic system to establish itself as a scientifically useful paradigm that leads to greater knowledge of the natural world, it should be able to show that the categories ‘carve nature at its joints’ such as being able to demonstrate distinct aetiological links. For any diagnostic system to establish itself as clinically useful it must show that use of diagnostic labels aids treatment decisions in a way that impacts on outcome. As reviewed above there is little evidence to support the ICD/DSM paradigm being able to provide either the basis for collecting scientifically useful knowledge or clinically useful treatment decisions. There is much evidence to suggest that instead they can cause significant harm. The only evidence based conclusion that can be drawn is therefore that formal psychiatric diagnostic systems like ICD and DSM should be abolished.

New paradigms

Relying on DSM/ICD diagnostic categories to organise research, services, and treatment does not contribute to improved outcomes for those experiencing mental distress and is associated with considerable harm.

Alternatives to ICD/DSM are therefore needed. We can and should do better. We have all the evidence we need to work on re-organising our approaches locally, nationally, and internationally to develop services that are evidence based and can reduce the amount of harm DSM/ICD has caused at the same time as improving outcomes. New paradigms that draw on the existing evidence for what improves outcomes and that incorporates the views of those who matter most – service users – can easily be developed and implemented. The following represents some good starting points:

1. Aetiology: As discussed in this paper there is a strong association between trauma, particularly early childhood trauma, and adversity and the subsequent development of mental disorders including psychosis. There is also a strong association between the degree of socio-economic inequality and levels of mental distress in any society. Other associations include dietary, lifestyle, family functioning and attachments. Research that examines the relationship between contextual factors and degrees of impairment, without trying to link them to formal psychiatric categories, has a greater likelihood of succeeding in developing useful scientific knowledge about mental distress. Moving the focus away from the eugenic-like search for genetic and neurological abnormalities will allow for greater acceptance of human diversity, and decrease the likelihood of human rights, political and social issues being inappropriately medicalised. Given the strong relationship between increasing acceptance of the diagnostic medical model and increasing stigma, abolition of DSM/ICD will also help in the fight against stigma.

2. Clinical: Decades of outcome research into treatment of psychiatric disorders shows, that despite the development of many new techniques, the outcomes being achieved in studies 40 years ago are similar to those being achieved now. In other words our advances in therapeutic techniques have not yet led to improvement in overall outcomes for service users. Research has found that certain intra-therapeutic factors such as the therapeutic alliance has a much greater effect on outcome than model or technique used and that extra-therapeutic factors such as social support has an even greater impact on outcome than intra-therapeutic ones.28,30,42 A variety of studies (in areas as diverse as psychotherapy services, community mental health services, substance misuse, and marital counselling) have found that incorporating ideas from this outcome literature, such as using session by session feedback on outcome and therapeutic alliance, can improve outcomes.30,42 The message from this research is that services can improve outcomes, not by using diagnostic categories to choose treatment models, but by concentrating instead on developing meaningful relationships with service users that fully includes them in decision making processes. International service user led movements, such as the ‘recovery’ movement, that focus on the inclusion of people in recovery from mental health problems as collaborators in research, service development, and treatment model development provide good examples of how this evidence can be developed to change institutional culture.71,72,73 Services in non-Western settings should be able to incorporate local beliefs and practices and the wholesale export of Western ethno-psychiatry can be stopped.

Developing the knowledge base and services in this manner would give mental health services and practitioners a better chance of improving the lives of those they work with. It will also help with breaking long standing barriers between mental health services and the rest of medicine, by allowing the mental health professions to focus on developing paradigms that are evidence based and which properly incorporates an understanding of how physical and mental well-being are closely related to each other. These non-diagnostic based paradigms can then assist in helping the many patients who present with physically unexplained symptoms or chronic conditions, which inevitably impact on their mental well-being, without needing to label them as ‘mentally ill’.

The real gift of psychiatry is what it can offer the rest of medicine that is more unique to this field, which is an understanding of the person in their context. Psychiatry has to sit at the confluence of a variety of disciplinary discourses (Sociology, anthropology, psychology, philosophy, medicine, cultural studies, politics, theology etc.) and it is this broader understanding of the human and their health and well-being that psychiatry ‘brings to the table’. By lazily importing the diagnostic model from general medicine we end up miss-selling and under-utilising the unique skills the profession of psychiatry brings to healthcare by the ‘dumbing down’ of what we do into simplistic diagnosis driven protocols that has more to do with successful consumer culture marketing than science. Changing to more evidence compatible paradigms is now long overdue.


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Sami Timimi
Consultant child and Adolescent Psychiatrist
Director of Medical Education
Lincolnshire Partnership Foundation NHS Trust
Visiting Professor of Child and Adolescent Psychiatry
Faculty of Health and Social Sciences
Lincoln University
International Critical Psychiatry Network

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Mental Health Campaigners Welcome New Book About Schizophrenia

Published in The Guardian, 5th July 2011.

Mental health campaigners welcome book about schizophrenia.

The letters, journals and scribbled observations of David, diagnosed with schizophrenia, have been collated for a new book.

By Mary O’Hara

Schizophrenia is perhaps the most widely misunderstood and misrepresented of all serious mental illnesses in popular culture and media. So, when first-person accounts offering insights into the experience of someone who has lived with schizophrenia come along, they tend to be welcomed by mental health campaigners as an antidote to misinformation. Such has been the case with David’s Box, a new book documenting the journals and letters of a young man diagnosed with the illness in 1964 who took his own life seven years later.

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Mental Health Campaigners Welcome New Book About Schizophrenia

The letters, journals and scribbled observations of David, diagnosed with schizophrenia, have been collated for a new book.

A positive piece published in the Guardian, 5th July 2011 by Mary O’Hara about this important new book – David’s Box: The journal and letters of a young man diagnosed as schizophrenic, 1960-1971, for which I have written a foreward.